Asthma Action Plan
Student Name
School
Parent/Guardian Name
Emergency Contact Name
Healthcare Provider Name
Date of Birth
School Phone
Parent/Guardian Phone
Emergency Contact Phone
Health care Provider Phone
ID #
Attention Parent/Guardian/School Personnel: ANY student with asthma (any severity) can have a SEVERE asthma attack.
Asthma is triggered by·  Exercise  Cold Air  Animal Dander Strong Odors  Grass/Pollen  Colds/Flu  Mold  Other
Controller Medicines at home
How Much to Take
How Often
time(s) per day
EVERY DAY!
Other instructions
Gargle or rinse mouth after use
 If student does not have any medication at school, notify parent immediately. Call 911 if symptoms persist longer than 10 minutes.
SPECIAL INSTRUCTIONS: WHEN I AM  doing well,  getting worse,  having a medical alert
I Feel Good
(Green Zone)
PREVENT asthma symptoms every day:
 Breathing is good, and
 No cough, wheeze, chest tightness, or shortness of breath During
the day or night, and
 Can work or play as normal.
 Peak Flow (for age 5 and up):
_
_____ to
_(80% - 100% of personal best)
Take my controller medicines (above) every day at home as
prescribed
Before exercise, take _
____puff(s) of __
with spacer (if available) 10 minutes before exercise
____
Personal Best Peak Flow is _____________
I Don’t Feel Good
(Yellow Zone)
 Cough, wheeze, chest tightness, or shortness of breath, or can
do some, but not all usual activities.
 Waking at night due to asthma symptoms.
CAUTION, continue taking every day controller medicines at home, AND:
Begin QUICK RELIEF medication right NOW
 Take _
____ puffs of ___
(if available).
_____
with spacer
 Wait 15 – 20 minutes. If symptoms are not better, repeat the
above dose and wait another 15 minutes.
Watch for Red Zone symptoms.
 Peak Flow (for age 5 and up):
_
_____ to _
___(50% - 79% of personal best)
 If symptoms return to GREEN ZONE wait for 15 minutes.
 If symptoms remain in the Green Zone, return to class and
continue using quick relief medicine _
puffs every
_
__ hours as needed.
 If NOT back in the Green Zone after the second dose of medicine, GO
TO THE RED ZONE
Medical Alert






(Red Zone)
EMERGENCY! Get help! Do not leave student alone!
Severe chest tightness, or
Very short of breath or uncontrolled cough, or
Nose opens wide or ribs show with breath, or
Quick relief medicine has not helped, or
Trouble talking or walking, or
Blue lips or fingernails, or drowsy or confused
Peak Flow (for age 5 and up) under _
Take  4 or  6 puff of _____
spacer (if available).
________________ with
Repeat every 10 – 15 minutes until paramedics arrive.
 Call 911 immediately and call Parent/Guardian
_50% of personal best)
Health Care Provider: My signature provides authorization for the above written order.
I understand that all procedures will be implemented in accordance with state laws and
regulations.
Student carry and self-administer asthma medications: Yes No
Print Provider Name/Credentials:
_________________________Signature
____________________Date
________
This authorization is valid for one year from signature date.
Parent Request and Authorization: I request that the school assist my child with the above asthma medication(s) and the Asthma Action Plan as
ordered by the health care provider in accordance with state laws and regulations. I understand that the medication must have a pharmacy label with the
name of the student and the health care provider. I give permission for the school nurse to communicate with the healthcare provider on matters related to
this Asthma Action Plan.
My child may carry and self-administer asthma medications: Yes No
Print Parent Name:
___________________Signature
_________________________Date
_________
Adapted with permission from Regional Asthma Management and Prevention (RAMP), a program of the Public Health Institute, for use by Oakland Unified School District, Health
Services
School Nurse: ____________________________________________________ Signature ___________________________________________ Date __________________
Health Services: 746 Grand Ave. Oakland, CA 94610 • (510) 273-1510 • (510) 273-1511 fax
Revised: July 2012